5/12/17. Pharmacy Practice Advancement: Policy Influences at the National Level. Disclosure. Learning Objectives

Transcription

1 Pharmacy Practice Advancement: Policy Influences at the National Level C. EDWIN WEBB, PHARM.D., M.P.H. FERRIS STATE UNIVERSITY SPRING SEMINAR MAY 16, Disclosure I have no actual or potential conflicts of interest in relation to this activity. 2 Learning Objectives Recognize opportunities for pharmacy practice advancement presented by national shifts in payment policy and benefit design to reward value and outcomes rather than volume of health care services. Define the key principles of patient-centered and team-based care that facilitate improved clinical, economic, and quality outcomes from the use of medications. Explain the emerging national trends in standardized direct patient care processes for pharmacists and their potential to support contemporary practice advancement. 3 1

2 Assumed Truths in Health Care Reform Payment Reform: â FFS and á bundles, quality/outcomes incentives Patient-centeredness (e.g., from boomers to millennials) Health care teams, PCMH s, and ACO s Risk sharing one and two-sided Proactive analysis of and care for populations Technology innovations and adaptations precision medicine pharmacogenomics clinical decision support using evidence-based standards health-it shift to interoperability MACRA 2015 game changer for medicine 18th time is a charm: MACRA repeals the 1997 sustainable growth rate for Part B payments Replaces the SGR with a new payment method meant to move physicians and some other providers toward alternative payment models (APMs) MACRA creates two available tracks MIPS: fee-for-service plus quality link APMs: accountable care organization or other risk-bearing organization 5 2

3 What is patient-centered care? The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one s person, circumstances, and relationships in health care. Donald Berwick, M.D. Former CMS Administrator President, Institute for Healthcare Improvement Health Affairs, August

4 Any recent significant experience as a real patient? Stop and Reflect What was it like? Did you feel: Fully informed about your diagnosis and care plan? Included in discussions/decisions about your care? Empowered/expected to question and discuss? Respected/valued as an individual? Part of the team s structure/activities? 10 What is team-based care? The health care we want to provide for the people we serve safe, highquality, accessible, person-centered must be a team effort. No single health profession can achieve this goal alone. Carol A. Aschenbrener, M.D. Then Executive Vice President Association of American Medical Colleges IOM Paper Team Members Pamela H. Mitchell University of Washington Matthew K. Wynia American Medical Association Sally Okun PatientsLikeMe C. Edwin Webb American College of Clinical Pharmacy Robyn Golden Rush University Medical Center Bob McNellis American Academy of Physician Assistants (former) Agency for Healthcare Quality and Research Isabelle Von Kohorn, Institute of Medicine (former) Valerie Rohrbach, Institute of Medicine 4

5 IOM Discussion Paper 2012: A framing definition Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers to the extent preferred by each patient to accomplish shared goals within and across settings to achieve coordinated, high-quality care. IOM Discussion Paper 2012: Necessary Principles of High-Performing Teams Shared Goals Clear (Distinct) Roles Mutual Trust Effective Communication Measureable Processes and Outcomes IOM Discussion Paper 2012: Necessary values of successful team members Honesty Discipline Creativity Humility Curiosity 5

6 So???..what does all this have to do with real pharmacy practice? 16 MTM Defined: Profession s Consensus 2005 MTM is a service or group of services that optimize therapeutic outcomes for individual patients. MTM services include medication therapy reviews, pharmacotherapy consults, anticoagulation management, immunizations, health and wellness programs and many other clinical services. Pharmacists provide MTM to help patients get the best benefits from their medications by actively managing drug therapy and by identifying, preventing and resolving medication-related problems. 17 MTM Defined: CMS, Medicare Part D MTM generally refers to activities intended to optimize therapeutic outcomes by ensuring that patients are taking their medications safely and as prescribed, addressing any barriers to their doing so, and bringing any medication issues to the attention of the treating physician. Under (d), a Part D sponsor must establish an MTM program that: Ensures covered Part D drugs are used to optimize therapeutic outcomes through improved medication use, Reduces the risk of adverse events, Is developed in cooperation with licensed and practicing pharmacists and physicians, May be furnished by pharmacists or other qualified providers. 18 6

7 5/12/17 CMS perspective on Part D MTM - ~ 2015 Evidence suggests that the MTM services currently offered by Part D plans fall short of their potential to improve quality and reduce unnecessary medical expenditures, most likely due to misaligned financial incentives and regulatory constraints. Competitive market dynamics and Part D program requirements and metrics may incentivize investment in these activities only at a level necessary to meet the minimum compliance standards. Currently, Part D statutory and regulatory MTM provisions require uniform service offerings to enrollees who meet the plan s program criteria, based on numbers of medications and chronic conditions and expected annual prescription drug costs. These criteria both over-identify and under-identify beneficiaries who are either experiencing or at-risk of experiencing medicationrelated issues and could benefit from MTM interventions. The result is that Part D MTM programs may not include the level of resources nor the type of activities that could have the greatest positive effect on beneficiary outcomes. 19 PCPCC defines comprehensive medication management (CMM) The PCPCC guide defines comprehensive medication management in the PCMH Included in AHRQ s Innovation Center Quality Toolkit 2nd Revision with Appendix AGuidelines for Practice and Guidelines for Documentation PCPCC Resource Guide: Integrating Comprehensive Medication Management to Optimize Patient Outcomes CMM Defined: PCPCC Comprehensive medication management is defined as the standard of care that ensures each patient s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended. Comprehensive medication management includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes. This all occurs because the patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient s medication experience and clinical outcomes. PCPCC Resource Guide: Integrating Comprehensive Medication Management to Optimize Patient Outcomes 7

8 22 Provider Status An experienced contrarian s viewpoint We would have had to look long and hard to find a more tone-deaf term for the major issue at hand for pharmacists - effective coverage/payment for pharmacists patient care services - in relationship to the current policy and delivery system issues just outlined but things may be starting to change a bit. To succeed, the effort must be grounded in a commitment to patients care, outcomes and quality, not to our own professional status..it can t be about US! As an isolated goal, achieving provider status guarantees the profession very little (see Murawski and Ives, AJHP 2011, JAPhA 2013) As an integrated part of broader practice change and payment policy change, it can help position pharmacists to actually be meaningful and effective providers

9 Relevant Existing Approaches Section 1861 of the SSA the holy grail Physician definition vs. physician services Non-physician providers Statute focuses FIRST on the services covered (PAID FOR!!!) by the Part B benefit, following by qualifications description NPs and PAs CSW PT Services Ph.D. Psychologist OT Services CRNA Ultimate Irony a provider of services means. a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1814(g) and section 1835(e), a fund. 25 Relevant Existing Approaches State-based Is it CDTM, mid-level or provider status? North Carolina (2000) clinical pharmacist practitioner Joint Regulatory oversight by BOP & BOM Differentiated training and credentialing requirements Protocol requirements New Mexico (1993) pharmacist clinician Primarily prescriptive authority initiative Requires diagnostic and physical assessment training equivalent to a physician s assistant (included in revised Pharm.D. curriculum) Direct supervision of a single physician Policy support outside of pharmacy due to concerns about access to primary care 26 Relevant Existing Approaches California s Solution (2013) a lesson? Amends the business and professional code to designate all pharmacists as health care providers Some progressive modifications to general scope of practice Establishes advanced practice pharmacist Education, training and/or specialist certification requirements beyond licensure Expanded scope of practice, not limited to a pharmacy setting Regulatory framework now essentially complete 27 9

10 5/12/17 So what are we still missing? With very limited exceptions, health insurance coverage and payment policies don t explicitly include medication management services as a defined benefit for discreet PAYMENT! A clearly defined what delivered using a consistent and standardized process of care More complete understanding that current trends in payment policy will increase the value over volume challenge for ALL providers and the future is no longer far away 28 Process of Direct Patient Care: Toward standardization and alignment. 29 Pharmacy organizations harmonization efforts: Enhanced standardization and professional scope of CPA/CDTM regulations at the state level; Recommended guidelines for the development and use of statewide protocols (SWP s) to improve access to products and care services that address important public health issues that most pharmacists are able to provide; Striving for greater precision and rigor in terminology reflecting pharmacists patient care practice activities; 30 10

11 Do you know this man? Photo copyright DreamWorks Studios 31 Roles vs. Responsibilities Some quotes from the Linda Strand Keynote at ACCP 2012: Linda, when what you do looks like patient care, sounds like patient care and is patient care, then I will pay you for patient care. (BCBS Minnesota executive circa 1995) Each of us developed our own clinical activities, which we define around ourselves, based on our special interests that emphasize our strengths, delivered on our preferred timetable. That is not a patient care service - that is a hobby. (On the early history of clinical pharmacy) 32 Responsibilities of Providers A philosophy grounded in an ethical framework that puts patients/families at the center of one s practice Clinical performance that is evidence-based, continuously accessible, and rigorously consistent in its process of care A process of care that is standards-based, recognizable, and understood by patients and the team A practice infrastructure that assures availability/exchange of essential clinical data, unfailing documentation of care, measures results, and validates value sufficient to justify payment 33 11

12 What Success Must Look Like in a Pharmacist s Direct Patient Care Practice The service can be described simply and in terms of what it can do for the patient The service has an ethical and fiducial foundation The service is based on standards of practice so that it can be delivered consistently -- one practitioner to the next -- and from one patient to the next The service integrates with the other providers on the health care team, using aligned and consistent terminology, philosophy, standardized care processes, and quality/outcome emphasis The service generates measureable, reproducible results that demonstrate value to others The service is paid for as other direct patient care is paid for (increasingly including emerging value-based payment models) 34 In the final analysis, providers must be fully accountable for the care and services they provide, particularly in terms of quality and outcomes; be committed to and focused on the patients/family who have given them permission to come into their lives; deliver care and services in the context of and alignment with national health policy goals and objectives; and OWN and ACCOMPLISH THE WORK that is the core of their particular expertise.while not adding work to the other clinicians on the care team. 35 Get The Medications Right! 36 12

13 Supplemental Resources for Continuing Professional Development Kaiser Family Foundation ( Excellent data source on Medicare policies, trends, expenditures National Committee on Quality Assurance ( Key organization in health system quality metrics development and application by Medicare/private payers Health Affairs ( Leading national health policy journal covering the widest range of health policy, delivery system, and payment issues. 37 Questions? 38 Pre-Test 1. The announced goals of the Centers for Medicare and Medicaid Services (CMS) to shift the vast majority of its payment structure for physicians and other providers services toward quality/value-based performance are intended to occur over the next: A months B. 2-3 years (correct) C years D. 2 decades 39 13

14 Pre-Test 2. Which of the following is not considered an essential principle of high-performing health care teams? A. Financial accountability (correct) B. Effective communications C. Shared goals D. Clear roles 40 Pre-Test 3. Which of the following elements of a pharmacist s state-authorized scope of practice will likely be impacted by current national trends in delivery system and payment policy reforms? A. Frequency of licensure renewal B. Required number of hours of ACPEapproved continuing education activities C. Structure and efficiency of collaborative practice agreements and clinical protocols (correct) D. Increases in the pharmacist-to-technician ratio allowed under state regulations 41 14